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George Johny
4/3/14 Lesile Wolcott

Direct Access The purpose of this document is to provide an overview about the problem of direct access in the practice of physical therapy. In this Literature review, direct access refers to patients seeking physical therapy care directly without first seeing a physician or physician assistant to receive a script or referral for physical therapy services. One of the problems that oppose direct access is that being treated by physical therapy is contingent upon the prescription or referral of a physician. Such a requirement does not recognize the professional training and expertise of the licensed physical therapist nor does it serve the needs of patients that require urgent physical therapy. The topic of direct access created a clash between two main primary care professionals, general practitioners and physical therapists. Jonathon Kruger, the manager of the APA's policy and professional standards divisions, and a physical therapist says, we felt we had the skills to become primary contact professionals. Moreover, evidence over the course of 35 years shows that patient satisfaction rates for physical therapists are even better than the rates of general practitioners (Eric Ries, 2011). Another problem that faces direct access is the issue of reimbursement, which places a clear constraint upon the direct access policy. Insurance companies require a physician referral to reimburse the patient. Physical therapists are required by law to decline serving their clients until they receive permission from a physician, who ultimately determines if they need physical

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therapy(Crout, 1998; McCallum, 2012; Massey, 2002).This literature review will immerse you into the conversation that is taking place about direct access in physical therapy. Act/Reimbursement Direct access is dependent upon the advocacy of its supporters, some of which are organizations like APTA and APA that are promoters and activists for their profession, physical therapy. Such organizations feel the necessity to pass the Medicare Patient act, as it will have major factors in the physical therapy profession (Massey, 2002; Moore, 2002; Muir, 2004). These organizations strongly urge their supporters to influence legislation to pass The Medicare Patient act. The act contains three statues that affect physical therapy which are the elimination of physician referral, defining a qualified physical therapist, and the division of different scopes of therapy. The different types physical therapy will give it a notion of legitimacy, as it will show patients that physical therapists have different expertise. The passing of this bill will help physical therapy to take a big step toward acquiring direct access. "In order for the plan of making direct access to nationally accepted in 2020, to happen, direct access must be recognized within each state act, and third party payers must recognize it," Massey believes. Reimbursement is when insurance companies compensate their clients who visit their physical therapists without a referral. Reimbursement is a major blockade that hinders the progress of direct access, while Medicare act is the solution to that problem (Crout, 1998; McCallum, 2012). In order to find the solution to the problem, reimbursement, the APA and APTA try to pass bills like Medicare act so that insurance companies would recognize physical therapy through direct access to be valid and reimburse their clients when they visit their physical therapist without a referral. Legitimizing direct access will in return making physical therapists autonomy genuine, thus proving the profession as a health care provider.

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Primary Care Providers/Implementation Based on the research of Boissonnault and Shoemaker, the implementation of direct access at a health care institution as a pilot showed great results, which lowered the wait time in emergency rooms with high satisfactory rates. This implemented program's success led to the institutional adoption of the direct access model in all physical therapy outpatient clinics. The research described the interdependent and collaborative relationship among physical therapists and physicians, which resulted in the implementation of a patient-centered practice model based on patients' choice. As a physical therapist, Ries believes that physical therapists have the skills to become primary contact professionals. Moreover, evidence over the course of 35 years shows that patient satisfaction rates for physical therapists are even better than the rates of general practitioners (Ries, 2011). Similarly to Ries, Ludvigsson and Scheele feel that physical therapists should be deemed primary care providers due to their patient satisfaction rates over general practitioners. They also have written and formed studies that show that patients do not primarily need general practitioners to acquire care. In new health models, physical therapists were placed in the emergency room to treat patients whose injuries are related to physical therapy rather than general practitioners (Ries, 2011). The results showed that most of the patients did not need to meet general practitioners, which in return decreased the wait time for the patients whose illnesses required general practitioners. Implementation of direct access and physical therapists as primary care providers are associated with one another. Moore says, "direct access does not designate physical therapists as primary care providers. It does not restrict patient access to other health care providers, but encourages collaborative relationships among physical therapists and physicians to assist the

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patient in meeting their goals, needs and expectations." The studies and models have shown that direct access is possible and legitimate in which patients and general practitioners were both satisfied with the outcomes, and as a result, direct access was adopted in those settings. Benefits were not only seen on patients but also general practitioners in which patients will be more satisfied with the decreased wait time while the general practitioners would only need to concentrate on patients that require their specific expertise rather than on procedures that can be performed by physical therapists. (Moore, 2002) There has been plenty of research on how direct access can produce efficient results while lowering costs to patients. There has also been research on how successful direct access was when implemented in public health care settings. With direct access increasingly being supported, there is no better time to figure out how to expand direct access to states that have little or no direct access. Research can be done on whether or not the majority of people will be in support direct access in those states. This can be done by asking private and public physical therapy clinic to administer a survey in which it presents few statements and see if the patients would agree to them. These exit poll style surveys will give organizations like the APTA a better idea of what state they should cover first. Brochures will also be given out to those clinics on the how direct access benefits their patients and list ways in which patients can support advocacy of direct access. Most direct access statues are covered state by state, in which they differ significantly. By allowing This research to happen will really benefit those organizations on figuring out why legislative bills didnt get passed in the past thus giving them a chance to figuring out the problem and make changes to pass direct access policies in those states.

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Background. Attaining professional autonomy is a high priority for physical therapists and their professional organizations. Direct access is dependent upon the advocacy of its supporters. Most states in the U.S were advocates for direct access, but to the extent to which it exists nationally was unknown. Objective. The purpose of this study was to map out the states that were most supportive of direct access to physical therapy services so that organizations like the apa, and apta would be able to work and integrate direct access in those states based on the level of support. Design. The study had two stages, a survey and a brochure/subscription. Methods. An online survey would be sent to all subscribers of both apa and apta organization. It will also be sent out to health care institutions both public and private. Upon the answers submitted in the survey will then move on to the next step, a brochure. The brochure will include ways in supporting the passing of direct access policies in their state as well as benefits it may bring to themselves or their clients. Limitations. The findings may not be representative health care clinic who are owned by private general practitioners of the fact that less clients would be visiting the clinic thus lowering their income. Conclusion. Professional legislation, the medical profession, politicians, and policy makers are perceived to act as both barriers to and facilitators of direct access. Evidence for clinical effectiveness and cost-effectiveness and examples of good practice are seen as vital resources that could be shared internationally, and professional leadership has an important role to play in facilitating change and advocacy.

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Work Cited Boissonnault, WG, MB Badke, and JM Powers. "Pursuit And Implementation Of Hospital-Based Outpatient Direct Access To Physical Therapy Services: An Administrative Case Report." Physical Therapy 90.1 (2010): 100-109. CINAHL Plus with Full Text. Web. 11 Mar. 2014. Crout, KL, JH Tweedie, and DJ Miller. "Physical Therapists' Opinions And Practices Regarding Direct Access... This Research Was Presented In Poster Format At The Annual Meeting Of The Massachusetts Chapter Of The American Physical Therapy Association, October 14-19, 1994, Sturbridge, Mass, And At The 12Th International Congress Of The World Confederation For Physical Therapy, June 25-30, 1995, Washington, DC." Physical Therapy 78.1 (1998): 52-61. CINAHL Plus with Full Text. Web. 12 Mar. 2014. Ludvigsson, Maria, Landn, and Paul Enthoven. "Evaluation Of Physiotherapists As Primary Assessors Of Patients With Musculoskeletal Disorders Seeking Primary Health Care." Physiotherapy 98.2 (2012): 131-137. CINAHL Plus with Full Text. Web. 12 Mar. 2014. Massey, BF, Jr. "2002 APTA Presidential Address. What's All The Fuss About Direct Access?." Physical Therapy 82.11 (2002): 1120-1123. CINAHL Plus with Full Text. Web. 15 Mar. 2014. McCallum, Christine, A., and Tom DiAngelis. "Direct Access: Factors That Affect Physical Therapist Practice In The State Of Ohio."Physical Therapy 92.5 (2012): 688706. CINAHL Plus with Full Text. Web. 9 Mar. 2014.

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Moore, J. "Government Affairs. Direct Access Under Medicare Part B: The Time Is Now! We All Must Work To Ensure That The Medicare Patient Access To Physical Therapists Act Becomes Law." PT: Magazine Of Physical Therapy 10.2 (2002): 30-32. CINAHL Plus with Full Text. Web. 15 Mar. 2014. Muir, J. "Direct Access In (Private) Practice." PT: Magazine Of Physical Therapy 12.6 (2004): 56. CINAHL Plus with Full Text. Web. 14 Mar. 2014. Ries, Eric. "Direct Results Around The World... ...Think Direct Access And Advancing Scope Of Practice Are Essentially American Issues? Think Again." PT In Motion 3.5 (2011): 20. CINAHL Plus with Full Text. Web. 11 Mar. 2014. Scheele, Jantine, et al. "Direct Access To Physical Therapy For Patients With Low Back Pain In The Netherlands: Prevalence And Predictors." Physical Therapy 94.3 (2014): 363370. CINAHL Plus with Full Text. Web. 18 Mar. 2014. Shoemaker, Michael, J. "Direct Consumer Access To Physical Therapy In Michigan: Challenges To Policy Adoption... [Corrected] [Published Erratum Appears In PHYS THER 2012 Mar;92(3):471]." Physical Therapy 92.2 (2012): 236-250. CINAHL Plus with Full Text. Web. 9 Mar. 2014.